companyname
returnaddress
DO NOT MAIL CORRESPONDENCE OR PAYMENTS TO THIS ADDRESS	logo	

	member.1.fname member.1.lname member.1.suffix
member.1.personal.address1
member.1.personal.address2
member.1.personal.city xmember.1.personal.state xmember.1.personal.zip 	
Notice Date:  currentdate

Member Name: member.1.fname member.1.lname member.1.suffix

Benefits Enrollment is Here!	
If you have any questions regarding your benefits or this notice, please log in to company.1.websiteurl.

companyname’s Benefits Enrollment begins on member.ae.opendate. Benefits Enrollment is your opportunity to make changes to your employee benefits such as adding and removing coverage for yourself and/or your dependents. Any changes made during the benefits enrollment period will be effective member.ae.effectivedate.

Log in to company.1.websiteurl today to review your options and other important information regarding your benefits.

In addition to reviewing and updating your benefits for the upcoming plan year, company.1.websiteurl is your one-stop-shop for your benefits through companyname.

•	Update your contact preferences to ensure you are receiving important information regarding your benefits.
•	Upload required documentation for your covered dependents.
•	Chat with a member of our team at any time – day or night.

Enrolling Online Is Easy & Secure

1.	Go to company.1.websiteurl and log in with your username and password. If you don’t know them, you may reset your username and password or Register as a first-time user. Your Company Key is company.1.companykey.
2.	Click Start Here to start your benefits enrollment.

You can also enroll using the MyChoice® benefits app on your smartphone or tablet.  Download the app through the Google Play Store for Android or the Apple App Store for iOS.  Once downloaded, log in to company.1.websiteurl to receive your access code.	
	Last Day to Enroll
Your elections must be completed no later than

member.ae.closedate.

Any changes will be effective
member.ae.effectivedate.	

What if I want to change my benefits later?
Once Benefits Enrollment closes, your benefits are set for the year. You cannot change or add coverage unless you have a qualifying life event or status change.

If you have any questions regarding your benefits or this notice, please log in to company.1.websiteurl.

Thank you,
companyname

Your Information
as of currentdate

A summary of information already available on your account is provided below.  Please review for accuracy and log in to company.1.websiteurl to make updates or review additional details as well as review a summary of your current elected benefits.

Once Benefits Enrollment closes, your benefits are set for the year!  You cannot change or add coverage unless you have a qualifying life event or status change.

YOUR INFORMATION	

Name
member.1.fname member.1.lname member.1.suffix 

Address
member.1.personal.address1
member.1.personal.address2
member.1.personal.city xmember.1.personal.state xmember.1.personal.zip 
	
Gender
member.1.personal.gender

Date of Birth
member.1.personal.dob	

DEPENDENT INFORMATION	
First Name	Last Name	Relationship	Gender	Date of Birth	
					
member.2.fname 	member.2.lname	member.2.relation	member.2.personal.gender	member.2.personal.dob	
member.3.fname 	member.3.lname	member.3.relation	member.3.personal.gender	member.3.personal.dob	
member.4.fname 	member.4.lname	member.4.relation	member.4.personal.gender	member.4.personal.dob	
member.5.fname 	member.5.lname	member.5.relation	member.5.personal.gender	member.5.personal.dob	
member.6.fname 	member.6.lname	member.6.relation	member.6.personal.gender	member.6.personal.dob	
member.7.fname 	member.7.lname	member.7.relation	member.7.personal.gender	member.7.personal.dob	
member.8.fname 	member.8.lname	member.8.relation	member.8.personal.gender	member.8.personal.dob	
member.9.fname 	member.9.lname	member.9.relation	member.9.personal.gender	member.9.personal.dob	
member.10.fname 	member.10.lname	member.10.relation	member.10.personal.gender	member.10.personal.dob	
member.11.fname 	member.11.lname	member.11.relation	member.11.personal.gender	member.11.personal.dob	

BENEFICIARY INFORMATION	
member.1.planelection.life.pu_id_name
member.1.planelection.life.beneficiary	
member.1.planelection.life2.pu_id_name
member.1.planelection.life2.beneficiary	
member.1.planelection.life3.pu_id_name
member.1.planelection.life3.beneficiary	
member.1.planelection.life4.pu_id_name
member.1.planelection.life4.beneficiary	
member.1.planelection.life5.pu_id_name
member.1.planelection.life5.beneficiary	
member.1.planelection.life6.pu_id_name
member.1.planelection.life6.beneficiary	
member.1.planelection.life7.pu_id_name
member.1.planelection.life7.beneficiary	
member.1.planelection.life8.pu_id_name
member.1.planelection.life8.beneficiary	
member.1.planelection.vollife.pu_id_name
member.1.planelection.vollife.beneficiary	
member.1.planelection.vollife2.pu_id_name
member.1.planelection.vollife2.beneficiary	
member.1.planelection.voladd.pu_id_name
member.1.planelection.voladd.beneficiary	

Your Benefits Enrollment Worksheet

This worksheet lists your benefit options and costs effective member.ae.effectivedate.  This worksheet was designed to aid you in reviewing your options prior to enrolling online. To enroll or make changes to these benefits, please complete your online enrollment before member.ae.closedate.

Once Benefits Enrollment closes, your benefits are set for the year!  You cannot change or add coverage unless you have a qualifying life event or status change.

Enrolling Online Is Easy & Secure

1.	Go to company.1.websiteurl and log in with your username and password. If you don’t know them, you may reset your username and password or Register as a first-time user. Your Company Key is company.1.companykey.
2.	Click Start Here to start your benefits enrollment.

You can also enroll using the MyChoice® benefits app on your smartphone or tablet.  Download the app through the Google Play Store for Android or the Apple App Store for iOS.  Once downloaded, log in to company.1.websiteurl to receive your access code.	
	Last Day to Enroll
Your elections must be completed no later than

member.ae.closedate.

Any changes will be effective
member.ae.effectivedate.	

In addition to reviewing and updating your benefits for the upcoming plan year, company.1.websiteurl is your one-stop-shop for your benefits through companyname.

This worksheet is for informational purposes only and may be used to help guide you through your online enrollment.
This worksheet does not need to be completed or returned.	
member.1.planelections.medicallong
	
member.1.planelections.mod2
	
member.1.planelections.pdg2
	
member.1.planelections.dentallong
	
member.1.planelections.visionlong
	
member.1.planelections.life
	
member.1.planelections.life2
	
member.1.planelections.vollife
	
member.1.planelections.vollife2
	
member.1.planelections.voladd
	
member.1.planelections.volsplife
	
member.1.planelections.volsplife2
	
member.1.planelections.volspadd
	
member.1.planelections.volchlife
	
member.1.planelections.volchlife2
	
member.1.planelections.volchadd
	
member.1.planelections.deplife
	
member.1.planelections.deplife2
	
member.1.planelections.std
	
member.1.planelections.std2
	
member.1.planelections.ltd
	
member.1.planelections.ltd2
	
member.1.planelections.voleeci
	
member.1.planelections.volspci
	
member.1.planelections.volchci
	
member.1.planelections.volacc
	
member.1.planelections.volhosp
	
member.1.planelections.cancer1
	
member.1.planelections.cancer2
	
member.1.planelections.legal
	
member.1.planelections.legal2
	
member.1.planelections.legal3
	
Health Savings Account	

For 2025, Health Savings Account (HSA) annual contribution limits are:

Individual coverage:	
$4,300	

Family coverage:	
$8,550	

Maximum limits are subject to change based on IRS Rulings.
Health Savings Account Annual Contribution Amount:  _________________

member.1.planelections.flex	

For 2025, Healthcare Flexible Spending Account (FSA) annual contribution limit is $3,200.  Healthcare Flexible Spending Accounts require an active election.  Maximum limits are subject to change based on IRS Rulings.
Healthcare Annual Contribution Amount:  _________________
	
member.1.planelections.flex2	

For 2025, Dependent Care Flexible Spending Account (DCFSA) annual contribution limit is $5,000.  Dependent Care Flexible Spending Accounts require an active election.  Maximum limits are subject to change based on IRS Rulings.
Dependent Care Annual Contribution Amount:  _________________